Reforming Health Care: Lessons Learned, and Lessons Forgotten

From the outset of their efforts to enact health care reform, the Obama White House has conspicuously attempted to avoid the pitfalls that doomed Bill and Hillary Clinton's attempt in 1994. Learning from the mistakes of that failure was made easier by the fact that many of the key players in the current White House and Congress had front row seats in 1994 as a once-in-a-generation opportunity was squandered.

Clearly the White House set out to follow a different playbook. For all her accomplishments and talents, the President wisely did not put Michelle Obama in charge of the effort. Nor did he appoint a modern-day Ira Magaziner -- a kind of policy wonk meets mad scientist -- to help create a new health care system.

Rather than try to create the system behind closed doors, the White House invited the key stakeholders in -- insurance companies, providers, pharmaceutical companies, retirees, unions. And rather than pillorying the industries that have a vested interest in the current system, they negotiated with them.

Instead of trying to deliver a fully-baked plan to Congress and insist upon its passage, the Administration has let Congress work through the issues and try to settle the details. Not surprisingly, this has led to very public and very ugly sausage-making that has clearly helped dampen many American's enthusiasm for health care reform.

But the one lesson this White House failed to heed from the last failure was one of message. Much like the Clintons in 1994, the Obama Administration has -- at least until now -- lost the message battle and it may cost them the war.

While it's hard to remember today, the stars were much more aligned 15 years ago for comprehensive reform than they are today.

A little-known Democrat, Harris Wofford, won a special Senate election in Pennsylvania in 1991 running almost exclusively on reforming the health care system. There was widespread anger and fear among voters that Bill Clinton successfully tapped into in his 1992 campaign, taking a page directly out of Wofford's upset victory (not coincidentally, both campaigns were managed James Carville and Paul Begala).

Clinton launched his campaign for health care reform with a well-received speech before a joint-session of Congress. In response to the speech, even then GOP Senate Leader Bob Dole said, "I think we can work with the President on this."

But for all the advantages they had, we all know the end of the story -- reform died on the vine. While the tactical missteps played important roles, it was the lack of a compelling message platform to package and sell comprehensive reform that doomed it.

While Hillary Clinton and Ira Magaziner were busy creating what looked to be a byzantine new health care system, the interests invested in the status quo were busy positioning reform as an expensive government takeover of the health care system (sound familiar?).

The insurance companies, small business and their Republican allies went on the offensive with a simple, but powerful message platform that said reform will put the government in charge of your health care, preventing you from choosing your own doctor and driving up costs. And they hammered the point that Clinton-style reform would cost jobs, as small businesses would be forced to close. This was a powerful argument as the nation was just beginning to emerge from a recession.

The opposition repeated these messages over and over with remarkable discipline through the limited communications channels of those bygone days -- advertising, media coverage and grassroots missives to Capitol Hill.

This is the lesson the Obama Administration and their congressional allies forgot. To date, they have failed to package and sell reform in a way that is compelling to the vast majority of Americans -- those who have insurance, but are fearful that they will lose it.

Instead, the Administration initially focused on the economic arguments for health care reform, tying it to long-term economic recovery. While there is no question that health care reform is necessary for a return to prosperity, it's a complex equation and one whose direct benefits are hard to touch and feel. Two essential principles of effective messages are simplicity and salience. The economic argument for health care reform is neither.

Focusing on the economics also begged the question of how reform would be paid for -- a Pandora's Box of massive proportions. By opening this Box, reform advocates lost control of the debate as Republicans seized on it as another example of the Administration's profligate tax and spend approach to government and the Blue Dogs among others took to posturing over increased budget deficits (as Paul Krugman recently pointed out in the New York Times, one might have more admiration for the Blue Dogs fiscal purity had they been similarly outraged by the trillion dollar Bush tax cuts for the rich).

While it's easy to second guess this approach now, the lesson from 1994 was clear. Health care reform is hard, it's complex and it's scary. If it's not packaged and communicated through a set of messages that are credible, simple and salient, it will fail.

A simple message -- if you have insurance, you won't lose it if you lose your job (a huge concern given the economic climate) and if you don't have insurance, you will have the opportunity to be covered -- repeated consistently and driven through the various congressional proposals would have made it much harder for Republicans to derail it.

Following his widely panned press conference, the President has begun to shift the tone of his rhetoric to focus on the human element of reform and what it will mean to all Americans. This is a welcome shift. The question is if it's too little, too late.